Sudden cardiac arrest (SCA) in athletes is usually related to an underlying structural or electrical cardiac abnormality such as hypertrophic cardiomyopathy, coronary artery anomaly or a genetic electrical conduction abnormality. In some cases, a normal heart can degenerate into a life-threatening ventricular arrhythmia following a blunt, nonpenetrating chest wall blow known as commottio cordis.¹

In this article, we highlight the efforts of US Soccer's medical team to improve education, awareness and training on the cardiac emergency action plan (EAP).²

Regardless of the etiology, potentially catastrophic SCA events can be effectively managed through a coordinated emergency response, early hands-only cardiopulmonary resuscitation (CPR) and timely defibrillation. High suspicion for SCA should be maintained in any collapsed and unresponsive athlete, and the EAP initiated without delay. The most important factors in SCA survival are decreasing the time to defibrillation through early recognition, presence of a trained rescuer to initiate CPR, and direct access through the use of an on-site automated external defibrillator (AED). CPR should be started immediately on any collapsed unresponsive athlete by bystanders including coaches, trainers and other athletes as a bridge to external defibrillation. Automated external defibrillator programs should be part of a comprehensive EAP for SCA that includes an effective communication system, training of potential first responders in CPR and AED use, acquisition of appropriate emergency equipment and routine practice and review of the response plan. An AED should be applied immediately for rhythm analysis and defibrillation if indicated and CPR provided until a defibrillator is available or medical assistance arrives. By decreasing response times and increasing access to early defibrillation, survival from SCA in athletics will be optimized.

Any AED program in the athletic setting must be organized as part of a comprehensive EAP for SCA. An effective EAP starts with a rapid communication system that links all athletic venues, practice facilities and other parts of campus to the emergency medical service (EMS) system and the local response team. The core elements of an effective EAP should include the following: 1) establishing an efficient communication system; 2) training of likely first responders in CPR and AED use; 3) acquiring the necessary emergency equipment, including access to early defibrillation; 4) predetermination of transportation routes for EMS; and 5) practice and review of the EAP at least annually.³ The EAP should be developed by school or institutional personnel in consultation with the local providers to assist in maximizing efficiencies. The plan should target less than 5 minutes from time of collapse to time of first shock with annual review and practice to demonstrate.^3,4

The US Soccer "Recognize to Recover" program video is an example of how a plan can be introduced, implemented and practiced. No EAP is a one size fits all solution but using this video to introduce the topic in your local market as an example of how it could be accomplished is a way to begin the conversation about how to get started. Full "buy-in" is required. Organizing your own plan is vital to its success. A mock SCA scenario is recommended as a practice method for the EAP and to review AED access and application. The existing EAP should be modified based on feedback from the EAP rehearsal as needed.

Finally, in August of 2018 US Soccer launched a coaching education platform. This contains a mandatory 30-minute player safety module called "Introduction to Safe and Healthy Playing Environments." Every coach licensed under US Soccer will be required to watch the training video in order to make them cognizant of cardiac emergency management. This same training will be mandated in the future for referee licensing.

Cardiac care of the athlete continues to evolve. Efforts at a national and state level continue to determine best practices for evaluation and care of athletes for prevention and management of sudden cardiac arrest. US soccer illustrates their efforts to advance awareness and preparedness for those athletes, spectators and coaches who may suffer cardiac arrest and will benefit from a well-designed and executed plan.

References

1. Maron BJ. Sudden death in young athletes. N Engl J Med 2003;349:1064-75.
2. US Soccer. Recognize to Recover: U.S. Soccer's Comprehensive Player Health and Safety Program. http://www.recognizetorecover.org
3. Drezner JA, Courson RW, Roberts WO, Mosesso VN, link MS, Maron BJ. Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. Clin J Sport Med 2007;17:87-103.
4. Hazinski MF, Markenson D, Neish S, et al. Response to cardiac arrest and selected life-threatening medical emergencies: the medical emergency response plan for schools: a statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation 2004;109:278-91.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Sports and Exercise Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Sports, Athletes, Reaction Time, Thoracic Wall, Coronary Vessels, Defibrillators, Cardiopulmonary Resuscitation, Heart Arrest, Death, Sudden, Cardiac, Emergency Medical Services, Cardiomyopathy, Hypertrophic, Arrhythmias, Cardiac

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